Healthcare Provider Details

I. General information

NPI: 1538182571
Provider Name (Legal Business Name): OKECHUKWU ANTHONY IBEANU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 03/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9135 PISCATAWAY RD STE 420
CLINTON MD
20735-2555
US

IV. Provider business mailing address

9135 PISCATAWAY RD STE 420
CLINTON MD
20735-2555
US

V. Phone/Fax

Practice location:
  • Phone: 301-828-2555
  • Fax:
Mailing address:
  • Phone: 301-828-2555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number15442R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberMD423582
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: